Surgery advice for overbite correction

[Melalb]

Hi,
I'm currently undergoing orthodontic treatment (invisalign) for overbite/overjet which requires surgery. I would like to get your unbiased opinion on the most suitable surgical approach for my case.

Ideally I would like to improve the following features:
- occlusion
- recessed lower jaw
- weak chin
- poor tooth show
- flat cheeks

So far I have consulted only with one local maxillofacial surgeon who suggested BSSO in conjunction with a genioplasty. I am currently in the process of obtaining more opinions however in the meantime I would really appreciate your input. 

Thank you

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[PloskoPlus]

The chin bone looks ok. I wouldn't get genioplasty.

[kavan]

Hi,
I'm currently undergoing orthodontic treatment (invisalign) for overbite/overjet which requires surgery. I would like to get your unbiased opinion on the most suitable surgical approach for my case.

Ideally I would like to improve the following features:
- occlusion
- recessed lower jaw
- weak chin
- poor tooth show
- flat cheeks

So far I have consulted only with one local maxillofacial surgeon who suggested BSSO in conjunction with a genioplasty. I am currently in the process of obtaining more opinions however in the meantime I would really appreciate your input. 

Thank you

I think it's great if what you're saying is that you can get SINGLE lower jaw surgery and chin for better lower face projection and bite. I'm assuming you were told the WISDOM tooth would need to be extracted before getting the BSSO.

Cheek augmentation can be considered at a later time. I think I already made an entry in your cheek thread.

[GJ]

Your curve of spee looks very exaggerated. What is the ortho trying to achieve? It seems if he flattens it you'll have an anterior open bite, and then the surgery becomes more complex.

To me you look like a candidate for linear without any rotation, but given your curve of spee that might change once you're done with ortho and ready for surgery. Try to get more info.

[PloskoPlus]

Is this before any orthodontic decompensation? Because it doesn't look like you have much room for a significant bsso, hence the genioplasty suggestion from the surgeon. IMO genioplasty would be a mistake.

[Melalb]

I think it's great if what you're saying is that you can get SINGLE lower jaw surgery and chin for better lower face projection and bite. I'm assuming you were told the WISDOM tooth would need to be extracted before getting the BSSO.

Cheek augmentation can be considered at a later time. I think I already made an entry in your cheek thread.

Yes, a single lower jaw surgery was proposed although my wisdom teeth can remain as is without extraction.
In your opinion: Could BSSO work in my case even without the wisdom teeth extraction as it has been suggested to me?
Would the BSSO create enough vertical lengthening without genioplasty? Or should I consider DJS?

Your curve of spee looks very exaggerated. What is the ortho trying to achieve? It seems if he flattens it you'll have an anterior open bite, and then the surgery becomes more complex.

To me you look like a candidate for linear without any rotation, but given your curve of spee that might change once you're done with ortho and ready for surgery. Try to get more info.

I wasn't aware of the exaggeration. How can you tell what curve of spee one has? I'm struggling to determine it in my ceph.
The orthodontic treatment is supposed to prepare me for a linear mandibular advancement but I'm not sure if the surgeon considers a rotation or not at this point in time. The preoperative orthodontic treatment was only designed for 6 months and I am close to be ready for the surgery.

Is this before any orthodontic decompensation? Because it doesn't look like you have much room for a significant bsso, hence the genioplasty suggestion from the surgeon. IMO genioplasty would be a mistake.

Yes, this was before any orthodontic treatment started (4 months ago). I recently had a 3D facial scan done and will try to upload additional pictures when I receive them.
When you say that I don't have much room are you referring to the wisdom teeth or the overjet?
Do you think I am a candidate for DJS with rotation rather than SJS? I believe that genioplasty is supposed to create vertical length as my face is rather short.

[kavan]

Wisdom teeth extraction is usually a pre-requisite for a BSSO as to reduce the risk of a fracture with both the extraction and BSSO cut. Particular risk of such is a call the surgeon makes.


If you look at your ceph in terms of what Plosko told you, you will see that a single BSSO would only bring your lower jaw out as far as the lower front teeth will make correct contact with upper front teeth. Hence, it won't advance you that much.  If you drop a vertical line from your lower lip and look where your CHIN is RELATIVE to that line, you will see that your chin is way BEHIND it. Hence, that's a basic indicator for advancing the chin forward. The female chin should be only a LITTLE behind that line.

DJS is considered in the event you consult with another surgeon and that is suggested for which he/she should give the reasoning.

With regard to the 'shortness' to your face, the shortness is NOT isolated to the lower '1/3rd'. On the contrary, the lower '1/3rd' casts longer than the 'middle 1/3rd'. 

[Melalb]

If you look at your ceph in terms of what Plosko told you, you will see that a single BSSO would only bring your lower jaw out as far as the lower front teeth will make correct contact with upper front teeth. Hence, it won't advance you that much.  If you drop a vertical line from your lower lip and look where your CHIN is RELATIVE to that line, you will see that your chin is way BEHIND it. Hence, that's a basic indicator for advancing the chin forward. The female chin should be only a LITTLE behind that line.

I assume that my current ortho treatment has already created some room for the advancement since the ceph was taken. However, I can't say how much though. My chin is roughly 7mm behind my lower lip so I would like to know if the chin could be advanced to the ideal position (little behind the lower lip) through a BSSO only or is a genioplasty also required to achieve the necessary advancement?

I'm getting more opinions from other surgeons and will post them once I have received them.

[kavan]

I assume that my current ortho treatment has already created some room for the advancement since the ceph was taken. However, I can't say how much though. My chin is roughly 7mm behind my lower lip so I would like to know if the chin could be advanced to the ideal position (little behind the lower lip) through a BSSO only or is a genioplasty also required to achieve the necessary advancement?

I'm getting more opinions from other surgeons and will post them once I have received them.

The chin advancement is an individual advancement to the chin that the BSSO does not give. From the photos, it looks like a modest BSSO is needed for the lips to line up. 'Modest' BSSO is pretty much in tune with your over bite not being a whole lot. The rest of the advancement needed for balance would be to the chin.

In general, the objective for a single BSSO would be to move the 'whole' mandible forward so the lower lip is 'in line' with the upper lip. The landmark drop down lines convey: 'A modest amount'. Now even with the BSSO, the chin is still going to be behind the drop down line from the chin. So, that would need to come forward too.  That is the GENERAL principle.

I would say you are lucky to have a situation that can be corrected by SINGLE jaw advancement with chin in same surgery.

[haven]

How much overjet do they intend to create if they plan to only advance the mandible? I'm seeing like 5-6mm from that xray. My eyes are bad though 

[Melalb]

I have had an online consultation with Dr. Gunson today who proposed DJS as apposed to SJS proposed to me by my local surgeon.
He explained that both my jaws have grown small with the lower jaw being even smaller relative to the upper jaw.
The DJS would entail small CW rotation of upper jaw and CCW rotation of lower jaw with a possible genioplasty which might or might not be needed depending on the jaw movements. His surgical approach would open my air ways, create more space for my tongue which feels cramped, provide better lip close and more relaxed facial appearance. In regards to the cheeks he mentioned that they are borderline flat and would look even flatter after the surgery due to the advancement of both jaws hence he proposed augmentation with hydroxyapatite at the time of the surgery. The surgical plan is yet to be emailed to me but would really appreciate your initial thoughts. Thank you

[kavan]

The surgical plan is basically depicted on the displacement diagram he gave and you posted here. It shows a much improved profile contour.

[GJ]

The DJS would entail small CW rotation of upper jaw and CCW rotation of lower jaw

How is that possible? To have the jaws moving in two different directions seems a good way to wind up with an open bite.
I feel something must have been misunderstood.

[kavan]

Her diagram reflects what looks like a HEFTY posterior downgraft which is CCW. Maybe she got mixed up or forgot to put another 'C' in front of the CW.

[ditterbo]

I got a little excited, thinking her local surgeon drew up that plan, only to re-read and see it was actually a Gunson proposal. Bummer - OP it's tough finding a cheaper Gunson surgeon that can do THAT surgical plan you got there, as my proposed posterior downgraft amount from Gunson looks very similar, a little more posterior downgrafting even. Surgeon's seem to conk out at 3-4mm of a posterior downgraft where Gunson likes to do more than double that to avoid aesthetically over-advancing the maxilla, I think.